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Background and Aim of the Study: Cardiac surgery during pregnancy represents a major challenge as it comprises a single operation for two survivors., Methods: Between 1988 and 2005, 16 pregnant women underwent cardiac surgery at the authors' institution. Among 14 patients with rheumatic mitral stenosis operated on due to clinical deterioration, closed mitral valvulotomy was performed in 12 cases (three urgently in the third trimester, nine at term concomitantly with cesarean delivery). Two patients underwent mitral valve replacement, again, concomitantly with cesarean delivery at term, while two others underwent emergency reoperation for mechanical valve thrombosis during the second trimester, using a strategy of high-flow, high-pressure perfusion with mild hypothermia., Results: A total of 12 closed mitral valvulotomies and four mitral valve replacements was performed. There was no maternal mortality, and only one stillborn occurred in the urgent closed valvulotomy group. The remaining 15 babies were born healthy., Conclusion: In addition to protective perinatal procedures, instances occur during pregnancy when urgent or emergency surgery becomes unavoidable due to life-threatening cardiac decompensation. In patients with mitral stenosis, which is the case in most scenarios, closed mitral valvulotomy is life-saving and offers low fetomaternal risk, as a viable, efficient and practical alternative to percutaneous mitral balloon commissurotomy. When cardiopulmonary bypass (CPB) becomes mandatory, the shortest possible periods of mildly hypothermic or normothermic CPB with a strategy of high flow-high pressure perfusion should be followed.